Other Relevant Forms
Utilization Review Complaint Forms
Utilization Review Forms – DWC UR Form 1
Pre-designation of Personal Physician / Change of Physician Forms
Notice of Pre-designation of Personal Physician Form – DWC Form 9783
Notice of Personal Chiropractor or Acupuncturist – DWC Form 9783.1
Primary Treating Physician Forms
Primary Treating Physician Permanent and Stationary Report (2005 rating schedule) – DWC Form PR-4
Primary Treating Physician Permanent and Stationary Report (1997 rating schedule) – DWC Form PR-3
Primary Treating Physician’s Progress Report – DWC Form PR-2
Application for Independent Medical Review (for employee)
Utilization Review Complaint Form (for provider)
Predesignation of Personal Physician Form – DWC Form 9783
Request for Independent Bill Review
Providers Request for Second Bill Review
Official Medical Fee Schedule Order Form
Doctor’s First Report of Injury
Request for Authorization for Medical Treatment
Physician’s Return to Work and Voucher Form
Medical Provider Network (MPN) Forms
Cover page for medical provider network application – DWC form 9767.4
Notice of medical provider network plan modification Labor Code 9767.8 – DWC form 9767.8
Sample initial written employee notification re: Medical provider network